APCU25MPB4 Delayed malignant MCA infarction following inferior STEMI and thrombolysis in a young smoker

Introduction Sequential cardio-cerebral ischemic events are rare and pose significant diagnostic and management challenges. Stroke occurring after thrombolytic therapy for acute myocardial infarction (MI) is an uncommon but serious complication. We report a case of delayed malignant middle cerebral artery (MCA) infarction following thrombolysis for inferior STEMI in a young smoker.Case Presentation A 42-year-old male smoker presented with inferior ST-elevation myocardial infarction (STEMI). He received intravenous Tenecteplase and during thrombolysis developed transient left-sided weakness and persistent slurred speech. Neurological symptoms initially improved. He underwent successful percutaneous coronary intervention (PCI) without immediate complications. On the third day post-MI, the patient developed worsening slurred speech and headache. Repeat brain CT revealed a malignant left MCA infarct. Neurosurgical consultation recommended decompressive craniectomy; however, the patient declined surgery and was managed conservatively with intravenous mannitol.Discussion This case highlights the potential for delayed and progressive neurological complications after thrombolysis for MI. While thrombolysis reduces mortality in STEMI, it carries a risk of haemorrhagic and ischemic stroke. Early neuroimaging and neurological assessment are critical, even if initial symptoms are transient. Multidisciplinary collaboration is essential for timely diagnosis and optimal management in such complex cases.Conclusion Rapid weight loss can precipitate sudden cardiac arrest and acute myocardial infarction in young adults with predisposing risk factors. Awareness and preventive strategies, including risk assessment and counselling on safe weight loss, are essential to avoid such catastrophic outcomes.